Provider Demographics
NPI:1801057708
Name:HUNTINGTON, MARY ANN Z (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN Z
Last Name:HUNTINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3101 E STATE ST
Practice Address - Street 2:SUITE 2120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-473-3275
Practice Address - Fax:208-473-3276
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014306A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000243Medicare PIN